Ind. IHCP Hospice Services Provider Reference Module, Section 4, Discharge With Cause

The Medicare hospice rules contain a section regarding hospice discharge, including specific requirements

for discharge with cause. The IHCP has the same documentation requirements for discharge with cause

as noted in 42 CFR 418.26. For discharge with cause, providers must follow the requirements outlined in

42 CFR 418.26(a)(3) and submit the required documentation to the PA-UM contractor.

Before the state Medicaid agency discharges an individual under this section, the hospice needs to:

• Complete the Medicaid Hospice Discharge form.

• Check the box “Other” as the reason for discharge.

• Specify “discharge for cause” in the explanation section.

• Attach the medical documentation that supports the discharge for cause requested by the hospice

medical director.

If a patient has an attending physician involved in their care, the physician should be consulted before

discharge and the physician’s review and decision included in the discharge note. If the member does not

have an attending physician, that fact must be reflected in the medical documentation supporting discharge

with cause. In those cases, the hospice medical director serves as the patient’s attending physician.

While the IHCP has provided specific documentation requirements for discharge with cause, the hospice

may still have to coordinate with the Indiana Department of Health (IDOH) Acute Care Unit for situations

where a Medicare beneficiary’s safety is compromised. Hospice providers should contact the IDOH Acute

Care Unit at 317-233-7474 under those circumstances, as the IDOH is the Centers for Medicare &

Medicaid Services (CMS) contracted agent for these case-specific coordination concerns.

The CMS offers guidance in its Medicare Benefit Policy Manual, Chapter 9, Section 20.2.3, regarding

coordination recommendations:

The hospice must notify the Medicare contractor and State Survey Agency of the circumstances

surrounding the impending discharge. The hospice may also need to make referrals to other

relevant state/community agencies (i.e., Adult Protective Services) as appropriate.

Discharge order: Prior to discharging a patient for any reason other than a patient revocation,

transfer, or death, the hospice must obtain a written physician's discharge order from the

hospice medical director. If a patient has an attending physician involved in in his or her care,

this physician should be consulted before discharge and his or her review and decision included

in the discharge note.

Effect of discharge: An individual, upon discharge from the hospice during a particular election

period for reasons other than immediate transfer to another hospice —

➢ Is no longer covered under Medicare for hospice care;

➢ Resumes Medicare coverage of the benefits waived; and

➢ May at any time elect to receive hospice care if he or she is again eligible to receive the

benefit.

Discharge planning: The hospice must have in place a discharge planning process that takes

into account the prospect that a patient’s condition might stabilize or otherwise change such that

the patient cannot continue to be certified as terminally ill.

The discharge planning process must include planning for any necessary family counseling,

patient education, or other services before the patient is discharged because he or she is no

longer terminally ill.

Once a patient is no longer considered terminally ill with a life expectancy of six months or less

if the disease runs its normal course, Medicare coverage and payment for hospice care should

cease. Medicare does not expect that a discharge would be the result of a single moment that

does not allow time for some post-discharge planning. Rather, it would be expected that the

hospice’s interdisciplinary group is following the patient, and if there are indications of

improvement in the individual’s condition such that hospice may soon no longer be appropriate,

then planning should begin. If the patient seems to be stabilizing, and the disease progression has

halted, then it could be the time to begin preparing the patient for alternative care. Discharge

planning should be a process, and planning should begin before the date of discharge.

In some cases, the hospice must provide Advanced Beneficiary Notification (ABN) or a Notice of

Medicare Non-Coverage (NOMNC) to patients who are being discharged. See the Medicare Claims

Processing Manual (CMS Pub. 100-04), Chapter 30 “Financial Liability Protections,” Section 50.15.3.1,

for information on these requirements.

During those situations where a hospice provider feels that a member has demonstrated significant

noncompliance with the hospice plan of care, the documentation standard referenced in the last paragraph

of the preceding excerpt from the Medicare Benefit Policy Manual, regarding the provision of an ABN or

NOMNC to patients who are being discharged, must be followed. It is very important that a hospice

provider perform the following:

• Have written clear admission policies.

• Inform the member of their responsibilities under the hospice benefit.

• Document thoroughly the issues of noncompliance before taking the concern to the Part A Medicare

Administrative Contractor (MAC) or IHCP prior authorization contractor.